Comprehensive analysis of risk factors for postoperative wound infection following radical mastectomy in breast cancer patients

Surgical site infections (SSIs) following radical mastectomy in breast cancer patients can significantly affect patient recovery and healthcare resources. Identifying and understanding the risk factors for postoperative wound infections (PWIs) are crucial for improving surgical outcomes. This retrospective study was conducted from June 2020 to June 2023, including 23 breast cancer patients who developed PWIs post-radical mastectomy and a control group of 46 patients without such infections. Comprehensive patient data, including variables such as intraoperative blood loss, hospital stay duration, body mass index (BMI), operation time, anaemia, drainage time, diabetes mellitus, cancer stage, white blood cell (WBC) count, serum albumin levels and preoperative neoadjuvant chemotherapy, were meticulously gathered. Statistical analyses, including univariate and multivariate logistic regression, were performed using SPSS software (Version 27.0). The univariate analysis identified several factors significantly associated with an increased risk of PWIs, including preoperative neoadjuvant chemotherapy, low serum albumin levels, advanced cancer stage, diabetes mellitus and reduced WBC count. Multivariate logistic regression highlighted anaemia, prolonged drainage time, diabetes mellitus, advanced cancer stage, reduced WBC count, hypoalbuminemia and preoperative neoadjuvant chemotherapy as significant contributors to the increased risk of PWIs. Anaemia, extended drainage time, diabetes mellitus, advanced cancer stage, low WBC count, hypoalbuminemia and preoperative neoadjuvant chemotherapy are key risk factors for SSIs post-radical mastectomy. Early identification and proactive management of these factors are imperative to reduce the incidence of postoperative infections and enhance recovery outcomes in breast cancer patients.

Effects of intraoperative Magnesium sulfate infusion on emergency agitation during general anesthesia in patients undergoing radical mastectomy: a randomized controlled study

BACKGROUND

Emergency agitation is a common postoperative complication in patients under general anesthesia, which can lead to unpredictable damages such as shedding of drainage tube and bleeding from the wound. The purpose of the study is to investigate whether intraoperative infusion of Magnesium Sulfate reduces the incidence of emergency agitation (EA) in patients undergoing radical mastectomy, and to evaluate its safety and efficacy.

METHODS

A total of 70 patients were randomly assigned to two groups: the Magnesium group (M group) and the control group (C group). After a routine intravenous anesthetic induction, patients in the M group received a 30 mg/kg bolus of intravenous magnesium during the first hour and then a continuous infusion of 10 mg/kg ×h until the end of the surgery, patients in the C group received 0.9% saline at the same volume and rate. The sedation-agitation scale (SAS) and the visual analogue scale were used to assess agitation and pain, respectively.

RESULTS

Compared to the C group, the M group reduced the incidence of EA significantly (odds ratio 0.26, 95% confidence interval 0.09-0.71, P = 0.009). The postoperative pain score of the magnesium sulfate group(0(0,1)) was lower than that of the control group(2(0,3)) at T0 (P = 0.011). Additionally, the M group required a lower dosage of remifentanil during surgery compared to the C group(300.4 ± 84 versus 559.3 ± 184 µg, respectively, P<0.001).

CONCLUSIONS

the intraoperative infusion of magnesium sulfate is a safe and effective method for reducing the incidence of emergency agitation in patients undergoing radical mastectomy.

TRAIL REGISTRATION

The study was registered in Chictr.org with the identifier: ChiCTR2300070595 on 18/04/2023.

Kaposi's Sarcoma on a Lymphedematous Arm following Radical Mastectomy

Chronic lymphedema predisposes for local Immune incompetence, manifested by development of Stuart-Treves syndrome, Kaposi's sarcoma and fibroma-like lesions. A 91-year-old female with multiple cancers developed classic Kaposi's sarcoma on a chronically lymphedematous arm 26 years after radical mastectomy and irradiation of the involved axilla. The Kaposi lesion partially responded to electron beam irradiation.

Evolution of radical mastectomy for breast cancer

Surgical treatment of breast cancer has been marked by a constant evolution since the Halsted radical mastectomy described in the late 19th century has become the current standard Madden radical mastectomy, a breast surgery that involves the ablation of tissue with the axillary lymphatic preserving both pectoral muscles. The purpose of this paper was to present the stages that have marked the evolution of this intervention and to provide an overview of the way breast cancer has been understood and treated in the last century.

Paravertebral Catheter for Three-Level Injection in Radical Mastectomy: A Randomised Controlled Study

INTRODUCTION

Paravertebral block (PVB) is an alternative to general anaesthesia (GA) for breast surgery. However, for extensive surgery multiple punctures are needed increasing the immanent risk of the method. The purpose of this study was to evaluate PVB via catheter and injections at three different levels. Primary outcome was the quality of postoperative analgesia, in particular, the number of patients requiring additional morphine.

METHODS

In a randomised single blinded clinical study patients scheduled for breast surgery including axillary approach, were randomly allocated to different anaesthetic techniques, n = 35 each. Patients received either GA with sevoflurane or PVB with catheter at level Th 4. In PVB-patients a 1:2 mixture of bupivacaine 0.5% and lidocaine 2% with adrenaline was injected sequentially 10 ml each at three different levels.

RESULTS

Complication-free catheter insertion was possible in all 35 scheduled patients. The need for postoperative analgesics was higher after GA compared to PVB (22 vs.14 patients); p = 0.056. Postoperative morphine consumption was 1.55 (GA) and 0.26 mg (PVB) respectively (p < 0.001). Visual rating score (VRS) for pain at rest and at movement was higher in GA patients on post anaesthesia care unit (PACU) as well as on the ward at 1-6 h and 6-12 h. Readiness for discharge was earlier after PVB (4.96 and 6.52 hours respectively). After GA the incidence and severity of postoperative nausea and vomiting (PONV) was higher, though not significantly. Patients' satisfaction was comparable in both groups.

CONCLUSIONS

Three-level injection PVB via catheter for extensive mastectomy was efficient and well accepted. Using a catheter may enhance safety by avoiding multiple paravertebral punctures when extended spread of analgesia is required.

TRIAL REGISTRATION

www.ClinicalTrial.gov NCT02065947.

Evaluation of symptoms of anxiety and depression in women with breast cancer after breast amputation or conservation treated with adjuvant chemotherapy

OBJECTIVE

Evaluation of the presence of symptoms of anxiety and depression in women treated for breast cancer who underwent surgical procedure using one of two alternative methods, either radical mastectomy or breast conserving treatment (BCT).

METHODS

A questionnaire survey involved 85 patients treated in a conservative way and 94 patients after breast amputation. Hospital Anxiety and Depression Scale (HADS), Beck Depression Inventory (BDI) and depression degree evaluation questionnaire were used in the study. The patients' esponses were statistically analyzed.

RESULTS

Based on the HADS questionnaire, the total anxiety level in the group of women treated with BCT was 6.96 points, while in the group of patients who had undergone mastectomy the value was 7.8 points. The observed results were statistically significant. In the case of depression, the following values were found: patients after amputation had 8.04 scale value points, and those after BCT had 6.8 scale value points. The observed differences were statistically significant. Negative correlation was found between the level of anxiety and depression. The total level of depression evaluated using the Beck scale was 16.3 points in the BCT group, which means that they suffered from mild depression, while in the mastectomy group the level was 19.6 points, which corresponds to moderate depression.

CONCLUSIONS

The level of anxiety and depression among women with breast cancer was influenced by the type of the applied surgical procedure and adjuvant chemotherapy. Demographic variables did not influence the level of anxiety and depression.

[Mastectomy without wound draining in case of mammary gland cancer]

It was performed the retrospective analysis of radical mastectomy results in 6994 patients with verified mammary gland cancer. The first group included 3957 patients after developed wound closure during radical mastectomy. It was used improved method of wound suturing in 2037 patients of the second group. The control group included 1000 patients after radical mastectomy for Madden with installation of drainage system. It was concluded that wound suturing without drainage system installation significantly decreases the frequency and severity of lymphorrhea, length of hospital stay. It is not necessary to use expensive materials such as polymers, adhesives, gels and optional equipment in case of wound suturing without drainage system installation. Initial technique improvement provided more pronounced positive results such as significantly decreasing of frequency, severity and duration of lymphorrhea, reduction of hospital stay length.

Contralateral intramammary silicone lymphadenitis in a patient with an intact standard dual-lumen breast implant in the opposite reconstructed breast

Silicone lymphadenopathy is a recognized complication of silicone gel implant rupture; the ipsilateral axillary lymph nodes are most commonly involved. We report imaging findings on a range of different imaging modalities and biopsy results in a case of biopsy-proven silicone lymphadenitis involving contralateral intramammary and axillary lymph nodes in a patient with an intact standard dual-lumen breast implant in the opposite reconstructed breast. This case demonstrates that in a patient with disrupted lymph drainage due to prior mastectomy and axillary node dissection for breast cancer treatment, silicone particles can migrate in a retrograde fashion via the ipsilateral internal mammary lymph nodes and reach not only the contralateral axilla but also the outer quadrants of the contralateral breast, even in the presence of an intact breast implant.

[Is standard radical mastectomy still a treatment option for select patients with breast cancer ?]

BACKGROUND

Currently, minimal surgery is the treatment of choice for most breast cancer patients. However, some patients with locally advanced breast cancer( LABC) require standard radical mastectomy( SRM) before or after systemic therapy.

PATIENTS AND METHODS

We reviewed the medical records of 7 patients with breast cancer who underwent SRM in our hospital between January 2007 and April 2013 and examined their clinicopathological features and prognostic outcomes.

RESULTS

The average patient age was 68 years. SRM was performed because of muscle invasion( n=6), Rotter lymph node metastases( n=3), and level III lymph node metastases( n=3). After SRM, the wound was closed by skin grafting in 2 of the 7 patients. With regard to postoperative complications, 2 patients required rehabilitation for shoulder joint stiffness, whereas wound infection and arm edema were encountered in 1 and 2 patients, respectively. During the median follow-up time of 26 (range; 4-69) months, 3 patients experienced recurrence. The metastatic sites in the 3 patients were the supraclavicular lymph nodes, the chest wall, and the liver, respectively.

CONCLUSIONS

Quality of life( QOL) following SRM was acceptable in the patients examined. SRM could be considered as a treatment option in select patients with LABC.

[The choice of reconstructive operation in the treatment of patients with breast cancer]

170 patients, operated on the reason of breast cancer, received reconstructive surgery. Of them 63 had simultaneous organ preserving surgery with extramammary tissues translocation; 52 had organ preserving operation with the use of reductional mammoplasty and 55 patients had subcutaneous mastectomy with nipple preservation. Results of the study demonstrate that the method of organ preserving surgery with extramammary tissues translocation has more possibilities. The second place is occupied by the method of subcutaneous mastectomy with nipple preservation or in combination with muscular thoracodorsal flap replantation. The most complicated and giving the worst cosmetic result is the use of TRAM plasty. The algorithm of choice of the reconstructive operation for patients with breast cancer was worked out. Long term follow up showed the tumor progression in 29 (17.1%), remote metastases in 15 (8.8%) and local recurrence in 6 (3.5%) patients after organpreserving surgery and in 2 (1.2%) patients after subcutaneous mastectomy.

[Postmastectomy syndrome after the radical treatment of the breast cancer with the preservation of the intercostal nerve]

Postmastectomy syndrome often follows the radical surgery oа the breast cancer. The intersection of the branches of the intercostal nerve is an infrequent cause of the postmastectomy syndrome development. We studied the long-term follow up results in 30 patients after radical mastectomy by Madden with preservation of the branches of the intercostal nerve on the level of Th1-Th3. The method demonstrated the decrease of the postmastectomy syndrome and the improvement of quality of life.

Early rehabilitation reduces the onset of complications in the upper limb following breast cancer surgery

BACKGROUND

Breast cancer (BC) is currently the most frequent tumor in women. Through the years, BC management has evolved towards conservative surgery. However, even minimally invasive surgery can cause neuromotor and/or articular impairments which can lead to permanent damage, if not adequately treated.

AIM

To clinically evaluate upper ipsilateral limb function and the impact of certain post-surgical consequences arising after invasive or breast-conserving surgery for early BC, by intervening, or not intervening, with an early rehabilitation program. To investigate physical morbidity after sentinel (SLND) or axillary lymph node dissection (ALND) and after reconstructive surgery in the treatment of early BC.

DESIGN

Observational prospective trial.

SETTING

Inpatient and outpatient treatment.

POPULATION

Eighty-three females participated in the study: 25 patients did not begin physiotherapy during hospitalization (Group A), 58 patients received early rehabilitation treatment (Group B).

METHODS

The patients of Groups A and B were compared with respect to the following criteria: shoulder-arm mobility, upper limb function, and presence of lymphedema. All patients were assessed at 15-30, 60 and 180 days after surgery.

RESULTS

Statistically significant differences, in favor of Group B, were encountered at the 180-day follow-up visit, especially with respect to articular and functional limitation of the upper limb.

CONCLUSION AND CLINICAL REHABILITATION IMPACT

The results of the present study show that early assisted mobilization (beginning on the first postoperative day) and home rehabilitation, in conjunction with written information on precautionary hygienic measures to observe, play a crucial role in reducing the occurrence of postoperative side-effects of the upper limb.

[Efficacy of ANTISTAX in treatment of postmastectomic oedema of the upper limb]

Analysed herein are the results of two-year treatment with Antistax of 50 female patients presenting with early stages of upper limb lymphedema (the 'preclinical' stage of 'transient' oedemas, mild-oedema stage). The control group consisted of patients who due to various circumstances received no regular treatment with agents decreasing limb oedema, including diuretics. The obtained results demonstrated undoubted efficacy of Antistax administered at early stages of postmastectomic lymphedema. Preventive administration of the agent makes it possible to delay and in the majority of cases to also prevent the development of lymphedema. Administration of Antistax in a combination with physiotherapeutic treatment makes it possible both in the first and second stages of the disease to preserve the cosmetic and functional state of the upper limb.

[Prevention of complications after surgery in patients with upper limbs' lymphedema]

The results of surgical treatment of patients with the fourth stage of the upper limbs' lymphedema was studied. Of all 170 patients with lymphedema, 16 (9.4%) had the fourth stage of the disease. The debulking procedures were performed in 15 patients (8 had standart operations, 7 - simultaneous rwo-stage operations). Beeing a preliminary stage of the radical surgical excision of lymphoedematously changed tissues, the liposuction allows a more precisional hemostasis for the accurate vessel visualization. It led to the 4,4 times decrease of the postoperative morbidity rate and shortened the time of the operation.

Stress-related cardiomyopathy in a 31-year-old woman

Stress-related cardiomyopathy (SRC), initially referred to as Tako-Tsubo cardiomyopathy and later as apical ballooning syndrome, has been largely observed in postmenopausal women. It is frequently precipitated by a stressful event. This is a case report of a 31-year-old woman who experienced SRC immediately after a bilateral mastectomy.

[Collagen-polyvinylpyrrolidone: a new therapeutic option for treatment of sequelae after radical mastectomy in women with breast cancer. Preliminary study]

BACKGROUND

Approximately 30% of women who undergo mastectomy without reconstructive treatment due to breast cancer present sequelae. These include paresthesias, keloid healing, hypoesthesia, lymphedema and limitation of the function of the ipsilateral upper extremity. We undertook this study to present the results using collagen-polyvinylpyrrolidone (Clg- Pvp) as treatment for posmastectomy sequelae in women with breast cancer.

METHODS

We conducted a unicentric, longitudinal and prospective clinical trial between August 1, 2007 and July 31, 2008. Included variables were age, lymphedema, limitation of the function of the ipsilateral upper extremity, collapse of the wound, keloid healing, paresthesias, and appearance of the surgical area. The appearance of the surgical area (aesthetic aspect) was evaluated before and 6 months after treatment was initiated. Clg-Pvp was administered weekly for a 6-month period.

RESULTS

Seven women were included with a median age of 49 years (range: 40-72 years). One patient (14.28%) presented lymphedema, two patients (28.57%) presented collapse of the wound, two patients (28.57%) had keloid healing, three patients (42.85%) experienced paresthesias, five patients (71.4%) reported pain, and five patients (71.4%) reported limitation of the function of the ipsilateral upper extremity. At the completion of the treatment, aesthetic improvement was statistically significant (p = 0.0020, Mann-Whitney U test).

CONCLUSIONS

Clinical and aesthetic results are good after application of Clg-Pvp for treating sequelae in women with breast cancer who underwent mastectomy without reconstructive surgery.

[Evaluation of the risk of developing lymphoedema of the upper limb in women subjected to motor rehabilitation after radical mastectomy]

The analysis included 86 women in whom lymphoedema occurred in the upper limn (ULL) after radical mastectomy. The analysis were carried out in this group of patients, as well as in a control group (patients without ULL) 14 somatic parameters were examined. These parameters were evaluated before the intervention. It was established that among the anthropometric traits examined, only the body mass, hip width, hip-shoulder index, Chest flattening index, BMI index, WHR index, Quetelet's index, Rohrer's index, Pignet-Verwaeck's index assume average values in women with ULL in the preoperative period (statistically significantly different from those which occur in women without this complication(. It was shown that the dispensary group of women ill with breast cancer with a statistically significantly high risk of developing ULL was made up of patients with a large mass (>69.2 kg), WHR (>0.94), Quetele's (>448.7), Rohrer's (>1.76) and Pignet-Verwaeck's (107.7). A slim body build and low indexe values appear to be a factor protecting from this occurrence of the complication.

Risks and benefits of needle use in patients after axillary node surgery

Lymphoedema may be triggered by any type of injection. This is not just an issue for the cured breast cancer patient but for any patient who has undergone under-arm (axillary) lymph node removal to any degree for any type of cancer. Standard advice given to patients following axillary node removal is to avoid any injection or blood pressure measurement on the ipsilateral arm. The evidence base in this area is severely lacking. Patients have reported frustration that nurses are not informed of contraindications in carrying out such procedures on patients at risk of developing swelling. This article discusses the current evidence available on the subject of non-accidental skin puncture (NASP) relating to the patient at risk of lymphoedema and provides guidelines for any professionals conducting such procedures for patients with a history of cancer. The results from a small audit of the guidelines are cited and they reveal that out of 14 patients who underwent NASP procedures in the at risk arm, no patients reported swelling to that limb within a month of these procedures.

Evidence-Based Risk Factors for Seroma Formation in Breast Surgery

BACKGROUND

Seroma is a common problem in breast surgery. The aim of this systematic review was to identify risk factors for seroma formation.

METHODS

Articles published in English were obtained from searches of Medline and additional references were found in the bibliographies of these articles. Risk factors were graded according to the quality and strength of evidence and to the direction of association.

RESULTS

One meta-analysis, 51 randomized controlled trials, 7 prospective studies and 7 retrospective studies were identified. There was no risk factor supported by strong evidence, but there was moderate evidence to support a risk for seroma formation in individuals with heavier body weight, extended radical mastectomy as compared with simple mastectomy, and greater drainage volume in the initial 3 days. On the other hand, the following factors did not have a significant influence on seroma formation: duration of drainage; hormone receptor status; immobilization of the shoulder; intensity of negative suction pressure; lymph node status or lymph node positivity; number of drains; number of removed lymph nodes; previous biopsy; removal of drains on the fifth postoperative day versus when daily drainage volume fell to minimal; stage; type of drainage (closed suction versus static drainage); and use of fibrinolysis inhibitor. In contrast, sentinel lymph node biopsy reduced seroma formation. Evidence was weak, or unproven, for other factors that were commonly cited in the literature.

CONCLUSIONS

Although a number of factors have been correlated with seroma formation, strong evidence is still scarce. However, there is evidence showing that sentinel lymph node biopsy reduces seroma formation.

Phantom breast sensations and phantom breast pain: a 2-year prospective study and a methodological analysis of literature

The first aim of this study was to assess prospectively the incidence of phantom breast sensations (PB sensations) and phantom breast pain (PB pain) in a sample of patients treated for breast cancer (n=204) by means of a modified radical mastectomy (n=82). Patients were assessed 6 weeks, 6, 12 and 24 months after mastectomy, by means of a questionnaire. After 24 months, assessments of 74 (90%) patients were available. Two years after mastectomy, PB sensations were present in 19% (n=14) of the patients and PB pain was present in 1% (n=1) of the patients. Over time the percentage of patients with PB sensations remained relatively stable (around 20%) but for PB pain the percentage reduced from 7% to 1%. The amount of suffering as a result of PB sensations or PB pain was very limited. PB sensations and PB pain are of little clinical relevance in the 24 months following mastectomy. The second aim of this paper was to analyse the influence of research methodology on the prevalences of PB sensations and PB pain previously reported. Research design, assessment method and publication date were recorded. Data were weighted according to the number of women investigated. Linear regression analysis was performed to analyse the influences of methodology on the prevalences of PB sensations and PB pain. Of the 29 studies identified, 23 were cross-sectional and 6 were prospective. In 17 studies patients were interviewed and in 12 studies a questionnaire was used. A prospective design resulted in prevalences of PB sensations and PB pain averagely 8% lower respectively 9% higher than in cross-sectional studies. The use of an interview resulted in prevalences of PB sensations and PB pain averagely 13% lower respectively 5% lower than questionnaire use. Prevalences of PB sensations and PB pain reduce averagely with 0.08% respectively 0.13% per year since 1950. It is concluded that research design and assessment method have a significant influence on reported prevalence of PB sensations and PB pain.

Omental Transposition for Lymphedema After a Breast Cancer Resection: Report of a Case

Lymphedema of the arm and hand is one of the major complications after a breast cancer resection. Conservative treatment for the treatment of lymphedema, such as compression garments and centripetal massage, is very important for these cases. However, if the lymphedema is difficult to control with conservative treatment and the patient's quality of life (QOL) is compromised due to swelling of the arms, surgical treatment should be considered. We used omental transposition to improve the status of lymphedema in the present patient whose left arm and hand had been swollen for 5 years, which thus prevented her from being able to lift her arm. After the operation, she was able to lift her left arm herself and perform tasks with her left hand, thereby obtaining a better QOL than before the operation regarding her left arm movement.

[Reduction of lymphatic drainage posterior to modified radical mastectomy with the application of fibrin glue]

OBJECTIVE

Our objective was to investigate the effectiveness of fibrin glue to reduce hemato-lymphatic fluid production after modified radical mastectomy (MRM) in women with breast cancer.

MATERIAL AND METHODS

A total of 43 women treated surgically were randomly assigned to receive 10 ml of fibrin glue at the end of the breast resection plus closed suction drains (n = 22), or drain system only as a control group (n = 23). Outcome variables were fluid collected in the drainage system measured each 24 h. Drains were removed when a 50 ml output per day was obtained. Seroma formation and flap complications were also investigated.

RESULTS

The average age was 48.36 +/- 8.9 years for the study group and 52.87 +/- 9.74 years for the control group (p = 0.11). Body mass index (BMI) ranged between 22 and 35 kg/m2: 28.1 +/- 2.7 vs. 29.92 +/- 4.0 kg/m2 (p = 0.27). A reduction of the fluid drained was observed from the first postoperative day in the study group in contrast with the control (174.55 +/- 64.69 vs. 281.22 +/- 116.91, p = 0.001). A correlation between the BMI and the exposed surgical area was also statistically significant (p < 0.002), as well as the day the drains were extracted (p < 0.05). The incidence of seroma formation was 9% in the study group and 34.78% in the control, a statistically significant finding (p < 0.05).

CONCLUSIONS

Fibrin glue locally applied to the surgical wound under the flap and axilla significantly reduced the amount and duration of lymphatic fluid produced after MRM with axillary dissection. Also, a significant reduction in the incidence of seromas was observed.

[Flap transplantation combined with liposuction to treat upper limb lymphedema after mastectomy]

OBJECTIVE

To investigate a new surgical method to treat unilateral limb lymphedem after radical mastectomy.

METHODS

10 cases of upper limb lymphedema after radical mastectomy were treated using flap transfer (the lateral thoracic skin flap or latissimus dorsi musculocutaneous flap combined with liposuction).

RESULTS

After the treatment, the upper limb perimeter reduced in varied degrees. Nuclear lymphatic radiography showed notable changes in lymphatic circulation. The effective results were steady during the follow-up of 3-18 months.

CONCLUSION

Flap transplantation combined with liposuction is a useful treatment for limb lymphedema from radical mastectomy.

Two cases of Kaposi's sarcoma mimicking Stewart-Treves syndrome found to be human herpesvirus-8 positive

Although angiosarcoma is the most frequent tumor arising in the clinical setting of chronic lymphedema, as in Stewart-Treves syndrome, Kaposi's sarcoma has also been reported in this setting, although rarely. We describe two women who developed Kaposi's sarcoma in the lymphedematous arm many years after surgery for breast cancer. Case 1 is a 92-year-old and Case 2 is an 81-year-old; they underwent left total mastectomy and axillary node dissection for infiltrating breast carcinoma in 1981 and 1982 respectively. At that time, neither patient received further treatment. Except for persistent lymphedema, both women did well until over fourteen years later when each noted the development of several purple asymptomatic plaques on the edematous arm. In both, the clinical diagnosis at the time of biopsy was angiosarcoma. However, histologic findings in both cases were typical for Kaposi's sarcoma. In addition, a nested polymerase chain reaction (PCR) for the detection of a 233bp segment of KSHV/HHV8 was performed on DNA extracted from the paraffin-embedded specimens and both cases were positive for this sequence. Histologic sections of both cases were also tested for KSHV by in situ hybridization and demonstrated a positive signal in the lesional cells in each case.

Conventional or adhesive external breast prosthesis? A prospective study of the patients' preference after mastectomy

After having been subjected to radical mastectomy for breast cancer, women are usually fitted with an external breast prosthesis. Different types of prostheses are available, but oncology nurses have few data enabling them to advise their patients adequately. In this prospective randomized crossover study of 101 women undergoing one-sided mastectomy for breast cancer, the self-adhesive breast prosthesis was compared with the traditional external prosthesis. Questionnaires were used to evaluate the woman's judgment of the prosthesis in relation to her final preference for one type of prosthesis. Complete data were available for 91 women, 59.3% of whom finally preferred the self-adhesive type. Preference was independent of age, randomization, order, or the possible use of adjuvant chemotherapy. Satisfaction with the self-adhesive prosthesis was independent of randomization order but satisfaction with the traditional type was significantly more when it was the first type of prosthesis. Preference for the self-adhesive prosthesis over the traditional type mas mainly related to an increased perception of the prosthesis as a part of the body. Preference for the traditional prosthesis over the other type was mainly related to the greater ease of application and the lesser local irritation of the skin. Findings from this study can be useful in oncology nursing practice.

Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities

Over the last eight years, the authors analyzed obstructive lymphedema of a unilateral upper extremity in a total of 27 females, comparing the use of supramicrosurgical lymphaticovenule anastomoses and/or conservative treatment. The most common cause of edema was mastectomy, with or without subsequent radiation therapy for breast cancer. As an objective assessment of the extent of edema, the circumferences of the affected and opposite normal forearms were measured at 10 cm below the olecranon of the arm. Twelve of these patients received continual bandaging. In these patients, the average excess circumference of the affected arm was 6.4 cm over that of the normal forearm; the average duration of edema before treatment was 3.5 years; the average period for conservative treatment was 10.6 months; and the average decrease in circumference was 0.8 cm (11.7 percent of the preoperative excess). Twelve patients underwent surgery and postoperative continual bandaging. In these patients, the average excess circumference was 8.9 cm; the average duration of edema before surgery was 8.2 years; the average follow-up after surgery was 2.2 years; and the average decrease in circumference was 4.1 cm (47.3 percent of the preoperative excess). These results indicated that supermicrolymphaticovenular anastomoses with postoperative bandaging have a valuable place in the treatment of obstructive lymphedema.

[Transposition of the pedicled latissimus dorsi myocutaneous flap for the treatment of lymphedema of the upper limb after radical mastectomy]

OBJECTIVE

The clinical study was to improve the surgical treatment to upper limb lymphedema.

METHODS

The author treated 12 cases of severe lymphedenia of the upper limb using the pedicled latissimus dorsi myocutaneous flap. The treatment was completed in one stage.

RESULTS

The results were satisfactory in all the cases during the follow-up period of one to three years. No recurrence occurred.

CONCLUSIONS

The method is a good treatment to secondary lymphedema of the upper limb after radical mastectomy as it possesses the advantages of casiness to perform, short operation time, reliable effects, very safety and accordance to physiology.

[Problems with arms are common after breast surgery. Lymphedema is a frequent complication in elderly women treated for breast cancer]

75 women aged 70 years or more at the time of operation for breast carcinoma were monitored regarding arm morbidity; median follow-up was three years. 19 women (25%) developed lymphedema; of these, nine belonged to a group of 12 that had undergone both modified radical mastectomy and postoperative radiotherapy. Of this group of 12, ten had impaired arm mobility. Approximately 30% of those with lymphedema had not been identified at routine follow-up, while 20% reported moderate to severe pain. 15 of the 75 reported numbness and pricking sensations in the arm; of these, only one had lymphedema, while six had impaired arm mobility. Having thus found that a substantial number of elderly women experience complications in the upper extremity after primary treatment for breast carcinoma, we feel it essential to consider these factors when planning treatment protocols.

The risk of angiosarcoma following primary breast cancer

Lymphangiosarcoma of the upper extremity is a rare and aggressive tumour reported to occur following post-mastectomy lymphoedema (Stewart-Treves syndrome). Haemangiosarcoma, a related rare tumour, has occasionally been reported to occur in the breast following irradiation. We conducted a case-control study using the University of Southern California-Cancer Surveillance Program, the population-based cancer registry for Los Angeles County, to evaluate the relationship between invasive female breast cancer and subsequent upper extremity or chest lymphangiosarcoma and haemangiosarcoma together referred to as angiosarcoma. Cases were females diagnosed between 1972 and 1995 with angiosarcoma of the upper extremity (n = 20) or chest (n = 48) who were 25 years of age or older and residing in Los Angeles County when diagnosed. Other sarcomas at the same anatomic sites were also studied. Controls were females diagnosed with cancers other than sarcoma during the same time period (n = 266,444). Cases and controls were then compared with respect to history of a prior invasive epithelial breast cancer. A history of breast cancer increased the risk of upper extremity angiosarcoma by more than 59-fold (odds ratio [OR] = 59.3, 95% confidence interval [95% CI] = 21.9-152.8). A strong increase in risk after breast cancer was also observed for angiosarcoma of the chest and breast (OR = 11.6, 95% CI = 4.3-26.1) and for other sarcomas of the chest and breast (OR = 3.3, 95% CI = 1.1-1.7).

[Stewart-Treves syndrome--lymphangiosarcoma in sever lymphostasis of arm after mastectomy]

Stewart-Treves Syndrome ('STS) is a rare, extremely malignant and quickly progressing tumor. It is angiosarcoma developing in lymphostasis of an arm after radical mastectomy for cancer. The patient aged 80 years was followed-up, in whom STS had developed 19 years after radical mastectomy. Clinical diagnosis was confirmed by pathomorphological examination of dermal biopsy. Advanced age and severe associated diseases made it impossible to carry out specific therapy. The patient died of intoxication and increasing cardio-vascular insufficiency 9 months after the onset of the disease.

Lymphoedema of the arm after primary treatment of breast cancer

The incidence of lymphoedema of the arm depends on the radical nature of the primary treatment-radical mastectomy modified radical mastectomy and breast-preserving operation. Adjuvant radiotherapy increased significantly the oedema rate of each operative modality. The quality of life could be improved by minimising the incidence of lymphoedema if current standards of breast-preserving surgery were generally practised.

Acquired lymphangiectasis following mastectomy and radiation therapy--report of a case and review of the literature

A woman noted vesicles and papules on her left upper extremity fifteen years after she underwent mastectomy and received radiation treatment for left breast carcinoma. The vesicles showed clinical and pathologic features of acquired lymphangiectasis. The skin lesions were successfully treated with shave excision followed by electrodesiccation and sequential peristaltic compressions twice daily.

Lymphangiosarcoma following mastectomy

This study reviews 16 cases of lymphangiosarcoma of the upper extremity after mastectomy for breast cancer (Stewart-Treves syndrome) was done at the author's institution from 1970 to 1992. Lymphangiosarcoma was diagnosed an average of 10.6 years (range, 5.6-18 years) after the diagnosis of breast cancer. Presenting signs included a bruise (6 patients); increased swelling (4); a red, raised lesion (2); a palpable mass (2); a blister appearance (1); and a non-healing eschar with continual bleeding (1). After biopsy, surgical treatment included forequarter amputation (8 patients), wide excision with grafting (5), and above-elbow amputation (1). Local recurrence of the lymphangiosarcoma occurred on the chest wall in 11 of the 16 patients after an average of 10.9 months. Metastasis occurred in 11 patients. (Metastasis occurred in 1 patient without local recurrence, and 1 patient with locally recurrent lymphangiosarcoma died of breast cancer before evidence of metastatic lymphangiosarcoma.) There are 2 long-term survivors who have lived 9.3 and 6 years, respectively, since the operation. One had been treated with a forequarter amputation and the other with wide excision. Early recognition and surgical treatment seem to offer the only chance for long-term survival.

[Stewart-Treves syndrome. Immunohistochemical study apropos of 2 cases]

Two women (63 and 68 years) presented with primary angiosarcomas of the skin which had developed on an area of chronic lymphoedema after radiosurgical treatment for breast cancer 4 and 13 years earlier. Immunohistochemistry tests formally eliminated epithelial metastasis and produced evidence in favour of lymphatic or capillary vascular proliferation. Endothelial affinity for anti-factor VIII and positive tests for certain markers of intermediary filaments (actin, vimentin) confirmed the vascular and conjunctive tissue origin of the tumours.

Elective hand surgery in the breast cancer patient with prior ipsilateral axillary dissection

BACKGROUND

We wished to determine if complications after elective hand surgery were greater in women with previous mastectomy and axillary dissection than in those without.

METHODS

We surveyed records of all women undergoing carpal tunnel release by the senior author (W.J.D.) from 1983 to 1993. The postaxillary dissection group (group A) was made up of 15 women; seven had some postdissection lymphedema. Group B was made up of 302 other patients who had not undergone breast surgery or axillary dissection. Anesthetic and surgical techniques were identical for both groups, with i.v. regional anesthesia used most commonly.

RESULTS

No patient in the axillary dissection group developed any postoperative infection or had any worsening of preexisting lymphedema or onset of new arm swelling after ipsilateral carpal tunnel release. The nonaxillary dissection group had a postoperative infection rate of 3.6%; all infections were superficial and resolved with conservative therapy. In addition, 31 women experienced other complications, including 13 with hand/finger stiffness and four with reflex dystrophy. Fifteen required formal hand therapy.

CONCLUSIONS

Women with prior ipsilateral axillary dissection can safely undergo elective upper extremity surgery, provided strict sterile technique and appropriate anesthetic and surgical precautions are observed. Patients having undergone previous axillary dissection should not be prohibited from future limb manipulations, including venepunctures, blood pressure measurements, or elective surgery.

Prospective randomized study of surgical morbidity following primary systemic therapy for breast cancer

The influence of primary systemic therapy in treating operable breast cancer on postmastectomy morbidity rates was investigated. The contribution of other risk factors was assessed by multiple logistic regression. Seventy-nine eligible patients were randomly allocated, 39 to undergo immediate modified radical mastectomy, and 40 to receive initial cytotoxic or endocrine treatment followed by mastectomy. Postoperative wound seroma, infection and necrosis were recorded prospectively. Fourteen minor and six major complications occurred in 17 patients treated conventionally, while 14 patients developed 11 minor and six major complications after systemic therapy (P > 0.4). Median hospital stay was 8 days for both groups. Age, smoking, immediate breast reconstruction and the type of primary systemic treatment given were not independent predictors of complication risk. Obesity emerged as a significant risk factor for postmastectomy complications (P = 0.015). Primary systemic therapy does not increase the rate of morbidity after mastectomy.

Modern therapeutic approaches to postmastectomy brachial lymphedema

Over the past 10 years we have treated 36 patients affected by upper limb lymphedema, associated with mastectomy and axillary dissection, by either macrosurgical exeresis or microsurgical techniques. All cases had been unresponsive to prior drug or physical therapy (pressure and thermal therapy). Preoperative upper limb status was thoroughly examined by evaluating volume measurements, dynamic lymphoscintigraphy, venous Doppler fluximetry, ultrasonography, and nuclear magnetic resonance. Selected tests were repeated during follow-up to obtain more statistically significant results. Twenty-five of the 36 patients in our series presented a grade II lymphedema and underwent Degni-Cordeiro's microsurgical indirect lymphatico-venous shunt (L.V.S.) surgery. Fifteen of the 25 also received fasciotomies performed along the posterior aspect of the forearm. Three of the 36 patients presented grade II lymphedema and upper limb venous hypertension. These were treated with multiple fasciotomies alone. The remaining eight patients presented grade III lymphedemas. Seven underwent Kondoleon's partial superficial lymphangectomy, and one was treated with Servelle's total superficial lymphangectomy. Of the 36 patients who underwent surgery, only 27 were checked at 6 months; 22 were seen at 18 months. The remaining patients were followed up for too short of a period of time to be considered. Results were arranged into three groups. Classification criteria were: reduction of upper limb dimensions and the presence of the pre-existing symptoms (episodes of lymphangitis, pain, functional deficits. Results were considered good (class 3), fair (class 2), or poor (class 1). A positive clinical picture (class 2-3) was seen in 74% (20/27) at 6 months and in 59% (13/22) at 18 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Lymphangiosarcoma of arm after chronic lymphedema: a rare long-term complication after radical mastectomy in breast cancer patients. Case report and overview

Lymphangiosarcoma after mastectomy was first described by Stewart and Treves in 1948. Today, this tumor associated with chronic lymphedema has become a rare entity, due to less radical surgery. Chronic lymphedema and lymphangiectasia of limbs preceding lymphangiosarcoma may not only be induced by radical mastectomy. Also post-traumatic, congenital, filarial-associated or spontaneous chronic lymphedema may be associated with lymphangiosarcoma. A time interval of years seems to be required before malignant changes supervene and lymphangiosarcoma develops. This paper describes a case with lethal and arising in an edematous arm years after radical mastectomy and irradiation. Current concepts of etiology, histopathology, immunohistology, diagnostic investigation, treatment and prognosis are presented.